Oncology Survivorship Care — Part 1: Survivorship Care Plans and Surveillance by Cancer Type
Survivorship care plan components, structure, and evidence-based surveillance schedules for recurrence monitoring in breast, colorectal, prostate, lung, lymphoma, and head and neck cancer survivors.
1. Survivorship Care Plans
1.1 Definition and Rationale
A survivorship care plan (SCP) is a formal document provided to cancer survivors at the completion of active treatment. It serves as both a summary of the treatment received and a forward-looking roadmap for ongoing surveillance, health maintenance, and management of potential late effects. Major professional societies recommend that every patient completing curative-intent cancer treatment receive a personalized SCP, ideally developed collaboratively by the oncology team and shared with the patient’s primary care provider.1 2
The SCP serves several critical functions:
- Creates a permanent record of cancer diagnosis, staging, and all treatments administered
- Establishes a schedule for surveillance testing to detect recurrence
- Identifies late and long-term effects for which the patient is at risk based on specific treatments received
- Provides guidance on health promotion activities
- Clarifies the roles of the oncologist, primary care provider, and other specialists in ongoing care
- Empowers the patient to participate actively in their follow-up care
1.2 Required Components of a Survivorship Care Plan
Treatment Summary
| Component | Details to Include |
|---|---|
| Cancer diagnosis | Primary site, histologic type, grade, stage (TNM and AJCC stage group), receptor status or molecular markers (e.g., ER/PR/HER2, KRAS, MSI status, PD-L1) |
| Surgery | Date(s), procedure(s), margins, lymph node involvement, reconstructive procedures |
| Radiation therapy | Dates, anatomic fields, total dose (Gy), fractionation schedule, boost fields, technique (IMRT, proton, brachytherapy) |
| Systemic therapy | Agents administered, regimen name, number of cycles, cumulative doses of cardiotoxic agents (e.g., cumulative doxorubicin dose in mg/m²), dates of treatment, dose modifications |
| Endocrine therapy | Agent, planned duration, start date |
| Targeted/immunotherapy | Agent(s), duration, notable toxicities experienced |
| Clinical trial enrollment | Trial identifier, treatment arm if known |
| Significant toxicities | Grade 3–4 adverse events, hospitalizations during treatment |
| Genetic testing results | BRCA status, Lynch syndrome, other cancer predisposition syndromes |
Follow-Up Care Plan
| Component | Details to Include |
|---|---|
| Surveillance schedule | Cancer-specific surveillance tests and imaging with recommended frequency and duration |
| Late effects screening | Tests and evaluations based on specific exposures (e.g., echocardiogram after anthracycline; thyroid function after neck radiation) |
| Health promotion | Exercise, nutrition, weight management, tobacco cessation, alcohol, sun protection |
| Psychosocial care | Screening for distress, referral resources for counseling, support groups, fear of recurrence programs |
| Provider roles | Which clinician is responsible for each aspect of care |
| Red flag symptoms | Signs and symptoms that should prompt urgent evaluation for recurrence |
| Contact information | Oncology team contact for questions, urgent concerns, and referral back to oncology |
1.3 Delivery and Communication
The SCP should be provided in written form (printed or electronic) at the final active treatment visit or shortly thereafter. Ideally, a dedicated survivorship transition visit should be scheduled to review the plan, discuss the patient’s concerns, and answer questions. A copy should be sent to the patient’s primary care provider and any other relevant specialists. Electronic health record (EHR)–integrated templates can facilitate both creation and dissemination of SCPs.1
2. Surveillance for Recurrence by Cancer Type
The following sections provide evidence-based surveillance recommendations for the six most common cancer types requiring structured survivorship follow-up. Recommendations reflect synthesis of international guidelines including schedules for history and physical examination, laboratory testing, and imaging.1 2 3 4
2.1 Breast Cancer Survivorship Surveillance
Breast cancer is the most extensively studied cancer type in the survivorship setting, with well-established guidelines for post-treatment monitoring.
History and Physical Examination
| Timeframe Post-Treatment | Frequency |
|---|---|
| Years 1–3 | Every 3–6 months |
| Years 4–5 | Every 6–12 months |
| Beyond year 5 | Annually |
Each visit should include a focused review of systems targeting signs and symptoms of local-regional recurrence (new breast or chest wall mass, axillary adenopathy, skin changes) and distant recurrence (bone pain, dyspnea, abdominal pain, neurological symptoms, unexplained weight loss). A careful breast and lymph node examination should be performed at every visit.
Breast Imaging
| Test | Schedule |
|---|---|
| Mammography (ipsilateral if breast-conserving surgery; contralateral in all patients) | Annually, beginning no sooner than 6 months after completion of radiation therapy |
| Breast MRI | Annually for patients with known BRCA1/2 pathogenic variants, Li-Fraumeni syndrome, or those who received chest radiation between ages 10 and 30 (e.g., Hodgkin lymphoma survivors); not routinely recommended for average-risk breast cancer survivors |
Laboratory and Advanced Imaging — Not Routinely Recommended
Routine use of the following tests in asymptomatic breast cancer survivors is not recommended based on evidence that they do not improve overall survival or quality of life:
- Tumor markers (CA 15-3, CA 27.29, CEA)
- Complete blood count or liver function tests
- CT scans (chest, abdomen, pelvis)
- PET/CT scans
- Bone scans
- Chest radiographs
These tests should be reserved for evaluation of specific signs or symptoms suggestive of recurrence.1
Endocrine Therapy Monitoring
| Agent | Monitoring |
|---|---|
| Tamoxifen | Annual gynecologic assessment; patient education regarding abnormal uterine bleeding (endometrial cancer risk); consider ophthalmic examination if visual symptoms (cataracts, retinopathy) |
| Aromatase inhibitors | Baseline and periodic (every 1–2 years) bone density (DXA); lipid panel annually; assessment of arthralgias at each visit |
Additional Breast Cancer Survivorship Considerations
- Patients with BRCA1/2 variants require discussion of risk-reducing surgery for contralateral breast and ovaries if not previously addressed.
- Annual dermatologic examination for patients who received radiation therapy.
- Assessment for lymphedema at each visit, including arm circumference measurements if clinically indicated.
2.2 Colorectal Cancer Survivorship Surveillance
Surveillance after curative-intent treatment of colorectal cancer (CRC) is designed to detect surgically curable local-regional recurrence, metachronous colorectal neoplasia, and resectable metastatic disease. Intensive surveillance has been associated with improved overall survival and earlier detection of recurrence compared to minimal follow-up.2 5
History and Physical Examination
| Timeframe Post-Treatment | Frequency |
|---|---|
| Years 1–2 | Every 3–6 months |
| Years 3–5 | Every 6 months |
| Beyond year 5 | Annually, focused on second primary risk |
Physical examination should include assessment for hepatomegaly, inguinal and supraclavicular lymphadenopathy, and digital rectal examination (for rectal cancer survivors).
Carcinoembryonic Antigen (CEA)
| Patient Population | Schedule |
|---|---|
| Stage II–III colon or rectal cancer (medically fit for intervention if recurrence detected) | Every 3–6 months for years 1–2; every 6 months for years 3–5 |
| Stage I | Not routinely recommended |
| Patients not candidates for curative salvage | Not recommended |
Computed Tomography (CT)
| Scan | Schedule |
|---|---|
| CT chest, abdomen, and pelvis | Annually for up to 5 years for patients with stage II or III disease who are candidates for curative-intent surgery of metastatic disease |
| CT chest alone | Consider in addition to the above on an alternating schedule (i.e., CT every 6 months for the first 3 years) in high-risk rectal cancer |
| Pelvic CT or MRI (rectal cancer) | Considered for locally advanced rectal cancer to detect pelvic recurrence; frequency varies by institutional protocol |
Colonoscopy
| Scenario | Schedule |
|---|---|
| Initial post-treatment colonoscopy | At 1 year post-resection (or within 3–6 months post-operatively if a complete preoperative colonoscopy was not performed) |
| If initial post-treatment colonoscopy is normal | Repeat at 3 years, then every 5 years thereafter if results remain normal |
| If advanced adenoma (≥1 cm, high-grade dysplasia, villous features, or ≥3 adenomas) is found | Repeat colonoscopy in 1 year |
| Patients with Lynch syndrome | Colonoscopy every 1–2 years |
PET/CT
PET/CT is not recommended for routine surveillance. It should be reserved for clinical scenarios where conventional imaging is equivocal or when there is a rising CEA with negative standard imaging.
Proctoscopy (Rectal Cancer)
For patients treated with local excision or watch-and-wait after complete clinical response, proctoscopy (with or without endoscopic ultrasound or MRI) is recommended every 3–6 months for years 1–2, every 6 months for years 3–5.
2.3 Prostate Cancer Survivorship Surveillance
Surveillance after curative-intent treatment of prostate cancer — whether by radical prostatectomy or definitive radiation therapy — relies primarily on serum prostate-specific antigen (PSA) monitoring, with imaging reserved for biochemical recurrence.3 6
PSA Monitoring
| Treatment Modality | Recurrence Definition | Schedule |
|---|---|---|
| After radical prostatectomy | PSA ≥ 0.2 ng/mL (confirmed on repeat measurement) | PSA every 6–12 months for years 1–5, then annually |
| After radiation therapy (EBRT or brachytherapy) | PSA nadir + 2.0 ng/mL (Phoenix definition) | PSA every 6 months for years 1–5, then annually |
Digital Rectal Examination (DRE)
| Schedule |
|---|
| Annually; some guidelines recommend DRE every 6–12 months for the first 5 years in patients post-prostatectomy to assess for local recurrence in the prostatic bed |
Imaging for Biochemical Recurrence
When biochemical recurrence is detected, imaging studies to localize recurrent disease include:
| Test | Indication |
|---|---|
| PSMA PET/CT | Preferred initial imaging modality for biochemical recurrence; can detect disease at low PSA levels (≥0.2 ng/mL post-prostatectomy) |
| Conventional imaging (bone scan, CT abdomen/pelvis) | Alternative if PSMA PET is not available; lower sensitivity at low PSA levels |
| Multiparametric MRI of the pelvis | For evaluation of local recurrence, particularly post-radiation |
Testosterone Monitoring (After Androgen Deprivation Therapy)
Patients who received ADT should have testosterone levels monitored. Recovery of testosterone to eugonadal levels typically occurs 6–24 months after cessation of LHRH agonists, but may be delayed or absent in older patients or after prolonged ADT.
Additional Prostate Cancer Survivorship Concerns
- Urinary function: Assessment for incontinence (post-prostatectomy) or irritative/obstructive symptoms (post-radiation) at each visit
- Sexual function: Assessment for erectile dysfunction; discussion of PDE5 inhibitors, vacuum devices, penile injections, or prosthesis
- Bowel function: Assessment for radiation proctitis symptoms (rectal bleeding, urgency)
- Bone health: DXA scan at baseline and every 1–2 years for patients on ADT or who received prolonged ADT
- Metabolic effects of ADT: Glucose, lipids, and cardiovascular risk factor assessment annually during and after ADT
2.4 Lung Cancer Survivorship Surveillance
Survivors of early-stage non-small cell lung cancer (NSCLC) treated with surgery, stereotactic body radiation therapy (SBRT), or definitive chemoradiation face ongoing risk of both local recurrence and second primary lung cancers. The annual risk of second primary lung cancer is approximately 1–2% per year.3 7
History and Physical Examination
| Timeframe Post-Treatment | Frequency |
|---|---|
| Years 1–2 | Every 3–6 months |
| Years 3–5 | Every 6 months |
| Beyond year 5 | Annually |
Chest CT
| Timeframe Post-Treatment | Schedule |
|---|---|
| Years 1–2 | Chest CT (with contrast for the first 2–3 years, then low-dose CT acceptable) every 6 months |
| Years 3–5 | Chest CT annually |
| Beyond year 5 | Annual low-dose CT (LDCT), continuing indefinitely for second primary lung cancer screening |
Not Routinely Recommended
- PET/CT for routine surveillance
- Brain MRI in asymptomatic patients (routine surveillance)
- Tumor markers
- Sputum cytology
Pulmonary Function
- Pulmonary function testing (spirometry, DLCO) should be performed post-operatively and as clinically indicated for patients with respiratory symptoms. Pulmonary rehabilitation referral for patients with significant post-operative or post-radiation functional decline.
Smoking Cessation
Active smoking status must be assessed at every visit. Smoking cessation is the single most impactful health intervention in lung cancer survivors, reducing the risk of second primary lung cancer, cardiovascular disease, and other smoking-related morbidity. Pharmacotherapy (varenicline, bupropion, nicotine replacement therapy) and behavioral counseling should be offered to all current smokers.
2.5 Lymphoma Survivorship Surveillance
Survivors of Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) treated with curative-intent chemotherapy, radiation, or combined modality therapy face unique long-term risks related to the young age at diagnosis (particularly HL), the use of anthracyclines and alkylating agents, and the radiation fields employed. Surveillance must address both relapse detection and late effects screening.4 8
Hodgkin Lymphoma Surveillance
| Timeframe Post-Treatment | History/Physical Exam | CT Imaging | Laboratory |
|---|---|---|---|
| Years 1–2 | Every 3–6 months | CT chest/abdomen/pelvis every 6–12 months for years 1–2 (consider PET/CT only if clinical concern for relapse; routine PET surveillance is not recommended) | CBC, ESR, metabolic panel at each visit |
| Years 3–5 | Every 6–12 months | CT annually (or as clinically indicated) | CBC, metabolic panel annually |
| Beyond year 5 | Annually | Not routinely recommended for relapse surveillance; transition to late-effects screening | Annual labs as clinically indicated |
Non-Hodgkin Lymphoma (Aggressive Subtypes, e.g., DLBCL) Surveillance
| Timeframe Post-Treatment | History/Physical Exam | CT Imaging | Laboratory |
|---|---|---|---|
| Years 1–2 | Every 3–6 months | CT every 6 months for the first 2 years | CBC, LDH, metabolic panel at each visit |
| Years 3–5 | Every 6–12 months | CT annually (or as clinically indicated) | CBC, LDH annually |
| Beyond year 5 | Annually | Not routinely recommended | As clinically indicated |
Routine PET/CT for Surveillance
Routine PET/CT surveillance in lymphoma survivors in complete remission is not recommended by current evidence-based guidelines due to high false-positive rates, patient anxiety, and lack of demonstrated survival benefit. PET/CT should be reserved for evaluation of suspected relapse based on clinical findings or abnormalities on conventional imaging.8
Late Effects Screening Unique to Lymphoma Survivors
Given that many lymphoma survivors (particularly HL) are treated at a young age, late effects screening is a critical and lifelong component of survivorship care. Key screening includes:
| Late Effect | Screening Recommendation |
|---|---|
| Breast cancer (after chest/mediastinal radiation, particularly ages 10–30) | Annual mammography AND breast MRI beginning 8 years after radiation or at age 25, whichever occurs later (but not before age 25) |
| Thyroid dysfunction (after neck/mediastinal radiation) | TSH annually beginning 1 year after radiation |
| Cardiovascular disease (after anthracyclines and/or mediastinal radiation) | See Part 2 for detailed cardiac screening protocols |
| Secondary solid tumors (lung, breast, thyroid, GI, skin) | Age-appropriate cancer screening; enhanced screening for high-risk populations |
| Lung cancer (after chest radiation, particularly with smoking history) | Annual low-dose CT beginning 5 years after chest radiation or at age 30 (whichever is later) for patients who received ≥20 Gy to the chest |
| Gonadal dysfunction | FSH, LH, estradiol (women) or testosterone (men) for patients with symptoms; fertility counseling |
| Pulmonary toxicity (after bleomycin, radiation) | Pulmonary function tests as clinically indicated |
2.6 Head and Neck Cancer Survivorship Surveillance
Survivors of head and neck squamous cell carcinoma (HNSCC) require close surveillance due to high local-regional recurrence rates (particularly in the first 2–3 years), the risk of second primary cancers in the aerodigestive tract, and the substantial functional morbidity associated with treatment (swallowing, speech, dental, thyroid, hearing).3 9
History and Physical Examination
| Timeframe Post-Treatment | Frequency |
|---|---|
| Year 1 | Every 1–3 months |
| Year 2 | Every 2–4 months |
| Years 3–5 | Every 4–6 months |
| Beyond year 5 | Every 6–12 months |
Physical examination must include thorough inspection and palpation of the oral cavity, oropharynx, larynx (indirect or fiberoptic laryngoscopy), neck, and skin of the head and neck region.
Imaging
| Test | Schedule |
|---|---|
| Post-treatment baseline CT or MRI of the head/neck | 3 months post-treatment completion (establishes the post-treatment baseline) |
| Follow-up cross-sectional imaging | As clinically indicated based on examination findings; some institutions perform CT or MRI every 6 months for years 1–2 |
| PET/CT | At approximately 12 weeks post-treatment for HPV-associated oropharyngeal cancer (to assess treatment response); not recommended for routine surveillance thereafter |
| Chest imaging (CT or chest X-ray) | Annually to screen for lung metastases and second primary lung cancer |
Thyroid Function After Neck Radiation
| Test | Schedule |
|---|---|
| TSH | Every 6–12 months starting 1 year after radiation, continuing indefinitely (hypothyroidism develops in 20–50% of patients after neck radiation) |
Dental and Oral Health
- Dental evaluation every 4–6 months for patients who received radiation to the oral cavity or salivary glands.
- Custom fluoride trays and daily fluoride application indefinitely to prevent radiation caries.
- Assessment for osteoradionecrosis risk before any dental extraction (hyperbaric oxygen evaluation may be needed).
- Saliva substitute and sialogogue (pilocarpine, cevimeline) management for radiation-induced xerostomia.
Swallowing and Speech Rehabilitation
- Formal swallowing assessment (speech-language pathology, modified barium swallow, or fiberoptic endoscopic evaluation of swallowing) for patients with dysphagia.
- Swallowing exercises and ongoing speech-language pathology support.
- Monitoring for aspiration and stricture formation, particularly after concurrent chemoradiation.
- Speech rehabilitation for patients after laryngectomy or those with significant voice changes.
Hearing Assessment
- Audiometry for patients who received cisplatin or radiation to the temporal bone region.
- Assessment for ototoxicity at baseline, during treatment, and periodically post-treatment as indicated by symptoms.
Nutrition
- Serial weight and nutritional status assessment at each visit.
- Dietitian referral for persistent weight loss or malnutrition.
- Monitoring and management of gastrostomy tubes, with goal of oral diet resumption when safe.
HPV-Associated Oropharyngeal Cancer Considerations
- Patients with HPV-positive oropharyngeal cancer have an excellent prognosis (approximately 80% five-year overall survival) and require long-term surveillance with awareness that late recurrences (beyond 5 years) can occur, though rarely.
- p16 or HPV testing should be documented in the treatment summary.
3. General Principles of Surveillance Across All Cancer Types
3.1 Symptoms Warranting Urgent Evaluation
Cancer survivors should be educated about “red flag” symptoms that should prompt immediate medical evaluation:
- Unexplained weight loss (>5% body weight in 6 months)
- New or worsening pain, particularly bone pain or headache
- Persistent or progressive fatigue not explained by other causes
- New palpable mass or lymphadenopathy
- Unexplained bleeding or easy bruising
- Persistent cough, dyspnea, or hemoptysis
- Change in bowel or bladder habits
- New neurological symptoms (weakness, numbness, confusion, vision changes)
- Night sweats, fever without an obvious source
3.2 Age-Appropriate Cancer Screening
In addition to cancer-specific surveillance, survivors should continue to receive age- and risk-appropriate screening for cancers unrelated to their primary diagnosis. This includes:
| Screening Test | Population | Frequency |
|---|---|---|
| Mammography | Women aged ≥40 (or enhanced screening per risk) | Per general population guidelines unless modified by treatment history |
| Cervical cancer screening (Pap/HPV) | Women aged 21–65 | Per general population guidelines |
| Colorectal cancer screening | Adults aged ≥45 | Per general population guidelines unless modified by treatment history or genetic risk |
| Lung cancer screening (LDCT) | Per USPSTF criteria (age, smoking history) | Annual LDCT |
| Skin cancer screening | All survivors, particularly after radiation | Annual full-body skin examination |
| Prostate cancer screening (PSA, DRE) | Shared decision-making in men aged ≥50 (or ≥40 if high-risk) | Per general population guidelines |
3.3 Duration of Cancer-Specific Surveillance
Most cancer-specific surveillance schedules extend through 5 years post-treatment, when the majority of recurrences for solid tumors have occurred. However, certain cancers have notable late recurrence patterns:
| Cancer Type | Late Recurrence Considerations |
|---|---|
| Breast cancer (hormone receptor–positive) | Recurrence risk persists beyond 10–20 years; annual mammography and clinical follow-up indefinitely |
| Renal cell carcinoma | Late recurrences up to 10+ years; extended surveillance recommended |
| Melanoma | Late recurrences described; lifelong skin and lymph node surveillance |
| Thyroid cancer | Lifelong surveillance with thyroglobulin and neck ultrasound |
| Hodgkin lymphoma | Late effects screening continues for decades |
References
Runowicz CD, Leach CR, Henry NL, et al. “American Cancer Society / American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline.” CA: A Cancer Journal for Clinicians, 66(1): 43–73, 2016. ↩︎ ↩︎ ↩︎ ↩︎
El-Shami K, Oeffinger KC, Erb NL, et al. “American Cancer Society Colorectal Cancer Survivorship Care Guidelines.” CA: A Cancer Journal for Clinicians, 65(6): 428–455, 2015. ↩︎ ↩︎ ↩︎
Denlinger CS, Sanft T, Moslehi JJ, et al. “NCCN Clinical Practice Guidelines in Oncology: Survivorship.” Version 1.2024. National Comprehensive Cancer Network (NCCN). ↩︎ ↩︎ ↩︎ ↩︎
Children’s Oncology Group (COG). “Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers.” Version 6.0, 2023. ↩︎ ↩︎
Meyerhardt JA, Mangu PB, Flynn PJ, et al. “Follow-Up Care, Surveillance Protocol, and Secondary Prevention Measures for Survivors of Colorectal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.” Journal of Clinical Oncology, 31(35): 4465–4470, 2013. Updated 2022. ↩︎
Resnick MJ, Lacchetti C, Penson DF, et al. “Prostate Cancer Survivorship Care Guideline: American Society of Clinical Oncology Clinical Practice Guideline Endorsement.” Journal of Clinical Oncology, 33(9): 1078–1085, 2015. American Society of Clinical Oncology (ASCO). ↩︎
Colt HG, Murgu SD, Korst RJ, Slatore CG, Unger M, Quadrelli S. “Follow-Up and Surveillance of the Patient with Lung Cancer After Curative-Intent Therapy: Diagnosis and Management of Lung Cancer, 3rd Edition: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.” Chest, 143(5 Suppl): e437S–e454S, 2013. ↩︎
Cheson BD, Fisher RI, Barrington SF, et al. “Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification.” Journal of Clinical Oncology, 32(27): 3059–3067, 2014. ↩︎ ↩︎
Cohen EEW, LaMonte SJ, Erb NL, et al. “American Cancer Society Head and Neck Cancer Survivorship Care Guideline.” CA: A Cancer Journal for Clinicians, 66(3): 203–239, 2016. American Cancer Society (ACS). ↩︎